Improving Healthcare for Transgender Patients in Diagnostic Imaging Departments

Sidsel Pedersen, MRT(R) and Virginia Sanders, RTR

In January 2017, National Geographic dedicated an entire issue to the Gender Revolution suggesting the binary model of male/female is shifting to a more diverse landscape regarding gender identity.

Today, there is a multitude of genders and various LGBTQ organizations have listed at least 30 ways in which people may currently identify and express. In order to treat all patients with the respect and dignity they deserve, healthcare providers need to be aware of this shift in the gender landscape. It is not necessary to discuss all of these genders in this article however, it is imperative that an understanding of the difference between gender and sex is established.

Genderbread Person

The Genderbread Person (Killermann, 2017) helps to gain a better understanding of identity, expression, biological sex and orientation relate to one another.

Gender identity is how we think about ourselves.

Gender expression is how we express ourselves. Our clothing style and hairstyle are examples of expression.

Biological sex refers to the reproductive organs we were born with; male, female or intersex.

Sexual orientation is whom we are attracted to, physically emotionally and spiritually.

Although Killermann uses biological sex in his Genderbread Person, a more inclusive and accepted term for the gender diverse community is, ‘sex assigned at birth’; therefore, we will use that term for the remainder of this article.

As healthcare professionals, we must provide equal care to all patients regardless of their sexual orientation and therefore we will not be discussing that aspect in this article. Additionally, a lesbian may express more masculine but still identifies as female therefore, there is no confusion about her sex assigned at birth.

It is important to be aware that the four factors of the Genderbread Person are independent of one another. A male sex assigned at birth may identify as a female and express as a combination of feminine and masculine traits. As well, a female sex assigned at birth may identify and expresses with very masculine traits.  As all these categories are on a sliding scale, you may also have someone right in the middle who does not identify as male or female (androgynous/non-binary).

A transgender person is someone whose gender identity and expression does not correspond with their sex assigned at birth.  The term transgender male refers to a person who identifies and expresses as male but whose sex assigned at birth is female. The term transgender female refers to a person who was born with male reproductive organs but identifies, expresses and wishes to live as a female.

Most government issued identification indicates only the assigned sex at birth. A formal process must be followed to have gender markers1 changed on government issued identification such as an Affidavit and a letter from a physician. This process may include mandating that a person must live as their desired gender full-time for one year, particularly for those who are pursuing sex reassignment surgery.  During that year, the identification will not match the expression. In 2018, the Alberta government began issuing drivers licenses with the gender marker “X” for those individuals that do not identify as either male or female. In Ontario, provincial health cards no longer require a gender marker or photo.

Healthcare providers may face new situations when providing health services to a member of the transgender community. Some challenging situations may be a result of:

  • Gender markers on identification may not be congruent with patient presentation
  • Legal name may not be their current name in use
  • Electronic medical records may inaccurately reflect the patients gender identity and/or expression

Having incongruent gender markers, or no gender markers, on a healthcare card may lead to some confusion for us in healthcare, as we may not address the person by the name they use or know to shield them appropriately from radiation. For example, if a pelvis exam is ordered on a transgender male who still has his ovaries. He may or may not have his gender marker congruent with how he identifies and expresses.  In any case, this example causes confusion to the technologist who may not know what to ask and place gonadal shielding on testes – not ovaries. In ultrasound, we may call in a patient that presents as female for a prostate exam and not understand what is happening. The confusion and uncertainty that we feel will also lead to patients feeling uncomfortable.

We believe that technologists must develop skills to better prepare and handle various situations including patients that do not have gender markers on their identification or in the situations where the gender markers do not match the patient’s expression and/or desired gender. We have a duty, bound by a Code of Ethics, to ensure all persons feel safe and respected.

The transgender community is marginalized – especially when it comes to healthcare situations. A US survey on the transgender population (2015) states that due to living as their desired gender, transgender people are nine times more likely to commit suicide than the rest of the population. Additionally, they face bullying and harassment on a regular basis. They often feel unsafe every time they walk out of their house.

So how can we help make the transgender community feel safe, comfortable and respected in our department?

We have suggestions that can help all technologist who are faced with a patient whose gender expression and identity are not congruent with their sex assigned at birth.

  • Use preferred name and pronoun by asking them
  • Explain why more personal questions are needed
  • Don’t make it weird

Use preferred name and pronoun

This is the simplest approach for all technologists and can make a very impactful difference for the patient.  Start your introduction with using your name and pronoun then ask the patient, “What may I call you?’. This will serve to help the patient identify you as an ally2 and start building patient rapport quickly. Once the patient has built trust with you, questions that are more personal will be more readily accepted and answered honestly by the patient.

Explain why more questions may needed

Next, it is important to explain why more questions are necessary to be asked.

Remember only ask questions that relate directly to the exam. It is important that all individuals with female sex assigned at birth are asked of any chance of pregnancy. Again, this can be a delicate topic, as some transgender males no longer identify as female or have female gender markers. Depending on the situation here are some examples of how to address the patient:

For exams that require choosing specific female/male gonadal shielding, it is important that the technologist inquires further “Are your reproductive organs internal or external?”

Don’t make it weird

We can’t stress this enough. Don’t make it weird.

In healthcare, we work with a wide variety of cultures, genders, creeds and races. When we are with someone who we feel is different physically, mentally or spiritually, we do our best to make them feel as comfortable and safe as possible.

The transgender patient is no different. If you are uncomfortable in any given situation however, the patient will feel uncomfortable too. If you make a mistake, apologize and move on. Give all patients the same respect and dignity.

Try your best to work with the patient by asking them what name/pronoun they would prefer, and ask the right questions to get the right answers in a professional and respectful way just as we would anyone else.


References

Killermann, S. (2017, 05 08). It’s pronounced metrosexual. Retrieved from It’s pronounced metrosexual: http://itspronouncedmetrosexual.com/2012/01/the-genderbread-person/#sthash.U771Lngb.dpbs

1 Gender marker refers to gender that is displayed on identification such as passport, drivers’ licences and healthcare cards.

2 Ally refers to a person who supports the LGBTQ community.


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